Patellar instability most frequently presents during adolescence. Congenital and infantile dislocation of the patella is a distinct entity from adolescent instability and measurable abnormalities may be present at birth. In the normal patellofemoral joint an increase in quadriceps angle and patellar height are matched by an increase in trochlear depth as the joint matures. Adolescent instability may herald a lifelong condition leading to chronic disability and arthritis. Restoring normal anatomy by trochleoplasty, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction in the young adult prevents further instability. Although these techniques are proven in the young adult, they may cause growth arrest and deformity where the physis is open. A vigorous non-operative strategy may permit delay of surgery until growth is complete. Where non-operative treatment has failed a modified MPFL reconstruction may be performed to maintain stability until physeal closure permits anatomical reconstruction. If significant growth remains an extraosseous reconstruction of the MPFL may impart the lowest risk to the physis. If minor growth remains image intensifier guided placement of femoral intraosseous fixation may impart a small, but acceptable, risk to the physis. This paper presents and discusses the literature relating to adolescent instability and provides a framework for management of these patients. Cite this article: Bone Joint J 2017;99-B:159-70.
Background: Evidence regarding the impact of psychological problems on recovery from injury has limited influence on practice. Mindlines show effective practice requires diverse knowledge which is generally socially transmitted.Aims and objectives: Develop and test a method blending patient, practitioner, and research evidence and using Forum Theatre to enable key stakeholders to interact with it. Assess this methods; impact on contributing individuals/groups; on behaviour, practice, and research; mechanisms enabling these changes to occur.Methods: Stage-1: captured patient (n=53), practitioner (n=62), and research/expert (n=3) evidence using interviews, focus groups, literature review; combined these strands using framework analysis and conveyed them in a play. Stage-2: patients (n=32), carers (n=3), practitioners (n=31), and researchers (n=16) attended Forum Theatre workshops where they shared experiences, watched the play, re-enacted elements, and co-produced service improvements. Stage-3: used the Social Impact Framework to analyse study outcome data and establish what changed, how and why.Findings: This approach enhanced individuals’/group knowledge of post-injury psychopathology, confidence in their knowledge, mutual understanding, creativity, attitudes towards knowledge mobilisation, and research. These cognitive, attitudinal, and relational impacts led to multilevel changes in behaviour, practice, and research. Four key mechanisms enabled this research to occur and create impact: diverse knowledge, drama/storytelling, social interaction, actively altering outcomes.Discussion and conclusions: Discourse about poor uptake of scientific evidence focuses on methods to aid translation and implementation; this study shows how mindlines can reframe this ‘problem’ and inform impactful research.EPPIC demonstrated how productive interaction between diverse stakeholders using creative means bridges gaps between evidence, knowledge, and action.<br />Key messages<br /><ul><li>Improving healthcare practice by means of research can be problematic.</li><br /><li>Knowledge translation models often neglect healthcare’s complexity and gaps between evidence, knowledge and action.</li><br /><li>The mindlines model shows how diverse healthcare knowledge is effectively melded, used, and transmitted.</li><br /><li>Forum Theatre enables key stakeholders to share and co-create knowledge, enhancing mindlines and hence practice.</li></ul>
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